Management of Asthma in Adults

Question 1

What cells are responsible for the effects of asthma?

Answer 1

Th2 Cytokines - (IL-5, LT)

Eosinophils

Mast cells

Question 2

What is the major contributor for the ari resistance of a tube?

Answer 2

The radius

Question 3

What is the difference between occupational asthma and work-exacerbated asthma?

Answer 3

Occupational has no prior history of asthma

Question 4

What is non-pharma management of chronic asthma?

Answer 4

Asthma Action Plan

Weight loss if ˄BMI

Vaccines – flu & pneum

Allergen avoidance

(inc. occup. Asthma)

Physiotherapy

Smoking Cessation

Bronchial Thermoplasty

Question 5

What are the drugs used to treat acute asthma attack and chronic asthma?

Answer 5

Question 6

What are the drugs to avoid during the treatment of asthma?

Answer 6

**β-blockers**

NSAIDS / Aspirin

Sedatives/strong opiates (unless in critical care)

Question 7

What are the non-pharma methods of treatment of acute asthma attack?

Answer 7

ITU/HDU

Ventilation

ECCO2R

Chest drain if

pneumothorax

Question 8

What are the benefits of inhalers?

Answer 8

• Small dose of drugs
• Delivery directly to the target organ (airways and lung)

•

•Onset of effect is faster

•

•Minimal systemic exposure

•

•Systemic adverse effects are less severe and less frequent

Question 9

What are the problems associated with metered dose inhalers?

Answer 9

• Needs co-ordination
• Elderly, young children, unwell can’t use effectively

Question 10

What are the benefits of spacers?

Answer 10

• Low oro-pharyngeal deposition of aerosol
• Reduced speed of the aerosol
• decreases bad taste associated with oral deposition
• reduced the risk of oral candidiasis and dysphonia with steroids
• Reduced “cold-Freon effect” in some

Question 11

What are the benefits associated with dry powder inhalers?

Answer 11

• Less coordination required
• Similar issues with deposition

Requires high inspiratory flow

Question 12

What is defined as the complete control of asthma?

Answer 12

• no daytime symptoms
• no night-time awakening due to asthma
• no need for rescue medication
• no asthma attacks
• no limitations on activity including exercise & normal lung function (in practical terms FEV1 and/or PEF>80% predicted or best)
• minimal side effects from medication.

–BTS/SIGN 2016

Question 13

What does SABA stand for?

Answer 13

Short acting beta 2 agonists

Question 14

Where do you find salbutamol?

Answer 14

MDI

DPI

Question 15

Where do you find terbutaline?

Answer 15

DPI

Question 16

What are the adverse side effects of beta 2 stimulants?

Answer 16

Question 17

What are regular preventers?

Answer 17

Low dose Inhaled Corticosteroids (ICS) - Preventers

•Beclomethasone

•

•Budesonide

•

•Fluticasone

•

•Ciclesonide

•

•Mometasone

Question 18

When do you start ICS?

Answer 18

• Using inhaled β2 agonist (“Reliever”) x3/week or more
• Waking one night a week or more due to asthma
• Requiring oral steroid for an exacerbation in the past 2 years
• Symptomatic x3/week or more

Question 19

What are the advantages of inhaled ICS?

Answer 19

Question 20

What are the side effects of Long term oral cortical steroid use?

Answer 20

Question 21

What are the long term side effects of inhaled long term steroids?

Answer 21

Dysphonia - difficulty in speaking due to a physical disorder of the mouth, tongue, throat, or vocal cords.

•Oropharyngeal Candidiasis

Question 22

When do you move up the steps from SABA to ICS?

Answer 22

If it is being used three times a week

Question 23

What is the next step of asthma management after administration of ICS?

Answer 23

Add inhaled low-dose ICS (normally as inhaled combination)

Question 24

What are the ICS long acting beta 2 agonists?

Answer 24

Question 25

What should you do if there is no response to LABA?

Answer 25

Stop using it and consider an increased dose of ICS

Question 26

What should you do if there is a benefit from LABA but control is still inadequate?

Answer 26

Continue LABA and increase ICS to medium dose Or Continue LABA and ICS and consider LRTA, SR theophylline, LAMA

Question 27

What are the possible high dose therapies?

Answer 27

Increasing the ICS up to high dose Addition of a fourth drug - LRTA, SR theophyline, beta agonist tablet, LAMA

Question 28

Give examples of Leukotrine receptor antagonists

Answer 28

Montelukast ## Footnote •Zafirlukast

Question 29

What is theophylline?

Answer 29

Phosphodiesterase inhibitor Adenosine receptor antagonist Weak bronchodilator

Question 30

What are the downsides to using Theophylline?

Answer 30

Many side effects Narrow therapeutic window Unpredictable metabolism - interacts with many drugs

Question 31

Give an example of an inhaled long-acting anti-muscarinic

Answer 31

Tiotropium Bromide

Question 32

What is the effect of LAMA?

Answer 32

Antagonises muscarinic acetylcholine receptor in bronchial smooth muscle ## Footnote Some limited evidence of benefit in asthma when added to ICS/LABA

Question 33

What are the side effects of LAMA?

Answer 33

Dry mouth GI upset Headaches Can rarely precipitate angle-closure glaucoma- emergency

Question 34

What is the very last stage of asthma treatment?

Answer 34

Daily steroid tablets Maintain high dose ICS Consider other treatments to minimise the use of steroids

Question 35

Give an example of a long term oral steroid

Answer 35

Prednisolone

Question 36

What dose is recommended for long term oral steroids?

Answer 36

Lowest oral dose that controls symptoms

Question 37

What is the result of abrupt cessation of oral steroid if on for over 3 weeks?

Answer 37

Acute adrenal insufficiency (failure of adrenal glands to produce endogenous glucocorticoid - can be fatal)

Question 38

What is the function of Omalizumab?

Answer 38

Monoclonal antibody against IgE For IgE mediated severe allergic asthma

Question 39

What is the cytokine that is responsible for driving the hypersensitivity in asthma?

Answer 39

Interleukin - 5

Question 40

What is the effect of Mepolizumab?

Answer 40

Monoclonal antibody against interleukin 5

Question 41

Who is mepolizumab given to?

Answer 41

People with poor asthma control (it is an injection) Long term steroid use or frequent use Blood eosinophilia

Question 42

What are other steroid sparing drugs?

Answer 42

Question 43

What are the non-pharmacological methods of asthma management?

Answer 43

Patient education and self-management plans Inhaler technique Smoking cessation Vaccinations (flu/pneumococcal) Allergen avoidance - removal needed if occupational asthma Bronchial thermoplasty - heating parts of the airway with a heater probe

Question 44

What is defined as moderate asthma?

Answer 44

Question 45

What is defined as acute severe asthma?

Answer 45

Question 46

What is defined as life-threatening asthma?

Answer 46

Question 47

What is defined as near fatal asthma?

Answer 47

Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures (504-507)

Question 48

What is the treatment of acute asthma - mild/moderate?

Answer 48

Question 49

What is treatment for acute asthma - severe?

Answer 49

Ipratropium is a short acting muscarinic drug * Consider IV MgSo4 if no response * Antibiotics if there is pneumonia / bacterial infection * CXR – pneumothorax + asthma = bad. Needs chest drain if unwell. * Involve senior medical staff including ITU if life threatening features –May need anaesthesia, intubation and ventilation in ITU –In extreme cases ECCO2R may be life saving (Extra cocorial CO2 removal (ECCO2R))